12-phase flow (12)

1. 1FRAME
   Agitation is a SYMPTOM not a diagnosis (Project BETA Domain 1; Holloman PMID 22461917) — set frame: medical/toxic-metabolic vs primary-psychiatric vs undifferentiated × mild/moderate/severe × pediatric/adult/geriatric/pregnant; medical workup runs in PARALLEL with behavioral containment, never deferred behind it
   inputs: age
   advance: Cause-frame hypothesis + population + severity band assigned; parallel medical-workup track opened
2. 2ENTRY
   Trigger from escalating motor activity, verbal threats/aggression, RASS/BARS/ABS score, staff or self danger, weapon/imminent danger, failure of verbal de-escalation, or vital-sign instability (medical-cause flag) (Project BETA Nordstrom + Richmond 2012 PMID 22461916 / 22461922; ACEP 2024)
   inputs: agitation_severity_score
   advance: Behavioral-emergency pathway activated + danger level documented
3. 3CONTEXT
   Substance use + timing (intox vs withdrawal), psychiatric history + prior effective agents, current medications (antipsychotic / serotonergic / anticholinergic / QTc-prolonging), comorbidity, pregnancy, baseline cognition (geriatric)
   inputs: substance_use_history, psychiatric_history, current_meds, pregnancy_status
   advance: Personalisation + risk-modifier data captured
4. 4RED_FLAGS
   POC glucose ALWAYS (hypoglycemia LR+ ≈ 25+); hypoxia + hyperthermia + abnormal vitals → immediately reversible life-threatening causes; head trauma; toxidrome; weapon / imminent danger → security + danger containment. These run BEFORE psychiatric attribution (Project BETA Nordstrom 2012 PMID 22461916; ACEP 2024)
   inputs: poc_glucose, vitals_spo2_temp
   actions: workup.hypoglycemia, workup.severe_agitation
   advance: POC glucose checked + vitals/SpO2/temp obtained + immediately reversible causes excluded or treated + danger contained
5. 5INITIAL_WORKUP
   POC glucose (if not already) + vitals + SpO2; targeted by medical-cause flag — tox screen + ETOH, ECG for QTc (pre-droperidol/haloperidol where feasible), CBC + renal, infection / hypoxia / structural workup; do NOT delay containment waiting for results (Project BETA Stowell/Nordstrom 2012 PMID 22461916)
   inputs: ecg, tox_screen_etoh, cbc_renal_infection_screen
   actions: panel.cbc, panel.renal
   advance: Mandatory glucose + vitals done; targeted tests sent per medical-cause flag (results not gating containment)
6. 6BRANCHING_WORKUP
   Medical-cause flag → delirium workup (acute onset + fluctuation + inattention + abnormal vitals → route psych.delirium.core.v1), toxidrome workup (anticholinergic / sympathomimetic / withdrawal → tox engines), encephalopathy / structural (CT head if focal deficit / head trauma / unexplained); primary-psychiatric → formal psych evaluation AFTER medical screen + stabilization (Project BETA Nordstrom 2012 PMID 22461916)
   inputs: toxidrome_pattern
   actions: workup.delirium, workup.encephalopathy, workup.hyperthermic_toxidromes, workup.acute_psychosis
   advance: Cause-directed workup obtained where triggered; cross-route activated if delirium / toxidrome / structural
7. 7DIFFERENTIAL
   Medical/toxic-metabolic (delirium, hypoglycemia, hypoxia, intoxication/withdrawal, anticholinergic / sympathomimetic toxidrome, structural/infectious CNS — pre-test ~0.40-0.50) vs primary-psychiatric (psychosis, mania, agitated depression — pre-test ~0.40) vs undifferentiated (default until medical cause excluded); can co-exist (intoxicated psychiatric patient); delirium-vs-psychosis pivot = acute onset + fluctuating course + inattention + abnormal vitals (LR+ ≈ 9 for delirium) (Project BETA Nordstrom 2012 PMID 22461916; cross-ref psych.delirium.core.v1 + psych.first-episode-psychosis.core.v1)
   inputs: medical_vs_psychiatric_features
   advance: Working cause-attribution assigned + cross-route triggers evaluated
8. 8RISK_STRATIFICATION
   RASS / BARS / ABS severity band → mild (RASS +1-+2 / BARS 5: verbal + environmental only) vs moderate (RASS +3 / BARS 6: oral chemical preferred if cooperative) vs severe (RASS +4 / BARS 7 + imminent danger: IM chemical ± physical restraint; hyperdynamic / excited-delirium phenotype failing IM → IM/IV ketamine rescue); QTc gates antipsychotic choice (Sessler 2002 PMID 12421743; Swift 2002 PMID 12377938; ADEPT Wilson 2017 PMID 28856060)
   inputs: agitation_severity_score
   advance: Severity band + restraint tier + agent selection + monitoring level + disposition documented
9. 9TREATMENT
   De-escalation FIRST always (Project BETA Richmond 10-domain verbal + environmental — PMID 22461922); oral preferred if cooperative (risperidone 2 mg / olanzapine 10 mg ODT / lorazepam 2 mg PO); IM if refusing/uncooperative (olanzapine 10 mg IM — NOT with IM benzo; OR haloperidol 5 mg + lorazepam 2 mg ± diphenhydramine 25-50 mg IM; OR droperidol 5-10 mg IM with QTc caution); IM ketamine 4-5 mg/kg (or IV 1-2 mg/kg) RESCUE for severe undifferentiated / excited-delirium hyperdynamic phenotype failing other agents WITH airway-capable monitoring; treat the underlying cause concurrently (glucose, O2, benzo for withdrawal, antidote for toxidrome) (Project BETA Wilson 2012 PMID 22461923; Cole 2016 PMID 26920090; Barbic 2021 PMID 33936339; Calver 2015 PMID 25920334)
   inputs: agitation_severity_score, current_meds
   advance: De-escalation attempted + least-coercive effective chemical restraint given if needed + underlying cause being treated
10. 10DISPOSITION
    Medical / ICU admission if reversible or toxic-metabolic cause requiring ongoing treatment (hypoglycemia resolved-and-monitored, toxidrome, sepsis, structural); psychiatric admission or transfer if primary-psychiatric with ongoing risk (route disease-specific engine); observation until sedation cleared + cause addressed + safe for level-of-care; escalate to suicidality pathway if SI surfaces (Project BETA Nordstrom 2012 PMID 22461916; ACEP 2024; cross-ref psych.suicidality.ed.core.v1)
    advance: Level of care set + cross-route engaged as applicable
11. 11MONITORING
    Continuous pulse-ox + cardiac monitoring if parenteral sedation given; oversedation / airway / hypoventilation watch (ketamine — laryngospasm/emesis/emergence; benzodiazepine + olanzapine combination — cardiorespiratory depression); serial RASS; physical-restraint reassessment intervals — visual q15 min + face-to-face q1-2h adult / q1h pediatric & geriatric per CMS / Joint Commission; remove restraint at earliest safe point (ACEP 2024; Project BETA Wilson 2012 PMID 22461923)
    advance: Sedation safely cleared OR stable monitored level of care + restraint removed or on documented reassessment schedule
12. 12FOLLOWUP
    Cause-directed — psychiatric follow-up / disease-specific engine; addiction services if substance-driven; delirium-prevention bundle if delirium (cross-ref psych.delirium.core.v1); restraint debrief + documentation + trauma-informed review with patient when calm; least-restrictive lesson for future episodes (Project BETA Knox/Holloman 2012 PMID 22461917; ACEP 2024)
    advance: Cause-directed follow-up arranged + restraint debrief documented + cross-route dossiers engaged